Content of Patient Records and Health Data Collection
Part 1 length 1page
Book Needed to complete assignment
Book: Lab Manual for Green/Bowie Essentials of Health Information Complete Lab
• Use the Deficiency Slip PDF to complete Lab Assignment 6-2 (Quantitative and Qualitative Analysis of Patient Records).
• Submit a completed deficiency slip for Case06, Case07, Case08, Case09, and Case10 (Appendix of Lab Manual).
Part 2 length ½ page
If you were to recommend a filing system, and then had to write a paragraph on: how to train someone to use that filing system. What would identify as the pro’s and con’s and why did you recommend that filing system?
Part 3 length ½ page
If you were to design a form for a new outpatient surgery department: what would you include? The form will capture all intake information.
What types of data would you collect? Why? What kind of directions would you provide to the front desk personnel and the patient for using the form.
Student Name ________________________________________________
Sequence Reports
Advanced Directives
Anesthesia Record
Ancillary Testing Reports
Consent To Admission
Consultation Reports
Discharge Summary
1 Face Sheet
History and Physical Examination
Nursing Section
Operative Report
Pathology Report
15 Patient Property Form
Physician Orders
Physician Progress Notes
Recovery Room Record
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LAB ASSIGNMENT 6-2: Quantitative and Qualitative Analysis of Patient Records
OBJECTIVES
At the end of this assignment, the student should be able to:
• Analyze patient records to identify quantitative and qualitative documentation deficiencies
• Complete deficiency forms, indicating quantitative and qualitative documentation deficiencies
Overview
Quantitative and qualitative analyses of discharged patient records identify provider documentation deficiencies (e.g., missing authentication, incomplete diagnoses on face sheet, and so on). This assignment will require the student to analyze records to determine whether or not documentation is complete, and to complete a deficiency form (Figure 6-1) for each case.
Figure 6-1: Deficiency Form (also located at companion Web site)
NOTE: Some health care facilities perform concurrent analysis, which means records are analyzed while patients are still in the facility receiving care. The advantage to this is that the record is conveniently located on the nursing unit where providers routinely care for patients. The disadvantage is that more than one provider needs to access records at the same time, often making them unavailable for analysis and completion.
Instructions
• 1. Go to the lab manual’s companion Web site and print one deficiency form for each patient record to be analyzed (10 total).
• 2. Refer to Appendix I, where Case01 through Case10 are located. NOTE: If you prefer, access these records at the lab manual’s online companion and review online.
• 3. Refer to the instructions for completing the deficiency form (Table 6-1), and review the Guide for Quantitative Analysis of Acute Care Hospital Discharged Inpatient Records (Figure 6-2).
Table 6-1: Instructions for Completing the Deficiency Form
o 1. Enter the case number (e.g., Case01).
o 2. Enter the patient number (e.g., 123456 from face sheet).
o 3. Enter the admission date from the face sheet. (This identifies the case analyzed in the event more than one record is stored in the same folder.)
o 4. Enter the attending doctor’s name.
o 5. Enter the other doctor’s name if a deficiency is present (e.g., emergency department physician).
o 6. Enter the other doctor’s name if a deficiency is present (e.g., consultant, surgeon, or anesthesiologist).
o 7–18. Review each report in the patient record, and compare to the Guide for Quantitative Analysis of Acute Care Hospital Discharged Inpatient Records (Figure 6-2):
? a. Circle Authenticate if the doctor needs to sign a report.
? b. Circle Document if the doctor needs to enter pertinent information to complete the report. On the line provided, enter specific information that needs to be documented (e.g., impression on physical examination).
? c. Circle Dictate if the doctor needs to dictate the entire report.
? d. Circle Date and/or Time if the doctor needs to date and/or time a report, progress note, physician order, or other document.
NOTE: Shaded areas on the deficiency form are included to assist you in determining the responsible doctor for each report.
o EXAMPLE 1: When reviewing the inpatient face sheet, if the attending physician documented abbreviations, circle No Abbreviations. The physician would then write out the meanings of abbreviations.
o EXAMPLE 2: When reviewing the record for the presence of a discharge summary, if it is missing, circle Dictate so that the physician is prompted to dictate the report. When the report is later transcribed and placed in the record, cross off Dictate and circle Sign. You won’t be able to complete that aspect of analysis during this assignment.
o EXAMPLE 3: If the patient had a consultation ordered, and the report is present on the record but not signed, enter the consulting doctor’s name after Other Dr: in column 3, and circle Signfor the Consultation Report entry.
Figure 6-2: Guide for Quantitative Analysis of Acute Care Hospital Discharged Inpatient Records
• 4. Review the Quantitative Analysis: Walk-Through of Case01 (Figure 6-3), which will familiarize you with completing the deficiency form for quantitative and qualitative analysis of discharged patient records.
Figure 6-3: Quantitative Analysis: Walk-Through of Case1
• 5. Analyze Case01, and go to the lab manual’s companion Web site to compare your completed deficiency form to the answer key. (Refer to Figure 6-3 for clarification of the answer key.)NOTE: When performing quantitative and qualitative analysis, be sure to refer to the Guide for Quantitative Analysis of Acute Care Hospital Discharged Inpatient Records (Figure 6-2), and ask the following questions as you review each record:
o Is patient identification included on each report in the record?
o Are all necessary reports present, completely documented, and authenticated?
EXAMPLE: Provider documents order for consultation in physician order. Was a consultation report dictated, transcribed, and filed in the record?
EXAMPLE: A chest X-ray is missing the impression: the radiologist is responsible for documenting it.
o Are all entries authenticated (signed)?
EXAMPLE: A resident documents the patient’s history and physical examination, and authenticates it. Did the attending physician document additional information to support or dispute the resident’s documentation? Did the attending physician also authenticate that entry?
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o Are the diagnoses and procedures documented on the face sheet complete? Are any diagnoses and/or procedures missing from the face sheet?
EXAMPLE: Attending physician documents diabetes mellitus on the face sheet of discharged patient record. Does documentation in the patient record support adult-onset type and/or insulin dependency?
EXAMPLE: Upon review of the discharged patient record, you notice that the responsible physician neglected to document several procedures that were performed during the stay.
o NOTE: On the job, follow your department’s procedure for communicating questions to the responsible provider regarding incomplete or missing diagnoses and/or procedures.
• 6. Analyze Case02 through Case05, and go to the lab manual’s companion Web site to compare your completed deficiency forms with the answer keys. NOTE: Re-analyze Case02 through Case05 for practice.
• 7. Analyze Case06 through Case10, and complete a deficiency form for each.
• 8. Submit completed deficiency forms to your instructor for evaluation.
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